Health Care Advance Directives, Living Will, Designation Of Health Care Surrogate Template, Uniform Donor Form (Page 9 of 9) in pdf

Health Care Advance Directives, Living Will, Designation Of Health Care Surrogate Template, Uniform Donor Form Page 9

The card below may be used as a convenient method to inform others of your health care advance

directives. Complete the card and cut it out. Place in your wallet or purse. You can also make copies

and place another one on your refrigerator, in your car glove compartment, or other easy to find place.

Health Care Advance Directives

I, ___________________________________

have created the following Advance Directives:

___ Living Will

___ Health Care Surrogate Designation

___ Anatomical Donation

___ Other (specify) _____________________

-----------------------

----------------------------

FOLD

Contact:

Name

_____________________________

Address _____________________________

_____________________________

Phone

_____________________________

Signature ____________________ Date _____

Produced and distributed by the Florida Agency for Health Care Administration. This publication can be

copied for public use or call our toll-free number 1-888-419-3456 for additional copies. To view or print

other publications from the Agency for Health Care Administration please visit

SCHS-4-2006

Health Care Advance Directives, Living Will, Designation Of Health Care Surrogate Template, Uniform Donor Form Page 9